How to document correctly with EHR templates

When using template-based electronic health records, physicians must make the most of the narrative space to complete the parts of the patient's story that may not be reflected through check-boxes and drop-down menus, according to experts interviewed by American Medical News.

This advice is in response to the burgeoning problem of EHR templates leaving out too much of the patient's health context and even potentially contributing to billing fraud.

As instruction issued from the Centers for Medicare & Medicaid Services in December 2012 stated, physicians are encouraged to avoid limited-space templates in particular. "Physicians ... should be aware that templates designed to gather selected information focused primarily for reimbursement purposes are often insufficient to demonstrate that all coverage and coding requirements are met," FierceEMR reported. "This is often because these documents generally do not provide sufficient information to adequately show that the medical necessity criteria for the item/service are met." 

To make the most of the narrative space offered by EHR systems, amnews experts recommended that physicians prioritize documenting the parts of the story that will be relevant to the next person who may open the record. "[Physicians] should also think about what information in the narrative might come off as confusing or incomplete," the article noted.

In addition, physicians might consider using speech-recognition technology, which can capture more nuances of the physician's thought process at the point of care. This technology can save physicians significant time in typing notes and allow information to be captured in detail before it is forgotten, noted Nick van Terheyden, M.D., chief medical information officer of a technology company that develops speech recognition and clinical language processing technology.

However, because speech-recognition systems can be error-prone, physicians should be sure to audit records for accuracy, added Albert Lai, Ph.D., assistant professor in the department of biomedical informatics at The Ohio State University College of Medicine.

To learn more:
- read the article from American Medical News

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